STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS. For Students

Transcription

1 STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS For Students 1. Fill out the student sections on pages 1, 2 and 5. Take all the pages with you to your physical exam appointment. 2. During your physical exam, be sure your provider s office completes pages 2, 3, and 4, including a review of the vaccinations recommended by the Centers for Disease Control for your travel destination(s). 3. You must ensure that the completed and fully signed Study Abroad Health Form (5 pages) is ed, faxed or dropped off at or mailed to Gonzaga Study Abroad office. ( studyabroad@gonzaga.edu; Fax: ; Mailing: 502 E. Boone Ave AD 85, Spokane, WA ; Office Location: Hemmingson Center Rm 102.) The health form may be completed up to five months prior to departure, and must be received by the deadline given to you by your program advisor. 4. This form (5 pages) is required by GU and is in addition to any forms required by your program. This requirement cannot be waived and is a condition of full acceptance into the program. 5. Some programs will require a separate health clearance form due to program requirements and/or country-specific risks. Be sure to get any additional/program-specific forms completed before the physical. For Medical Providers Students who wish to study abroad must be cleared by a health care provider. When determining a student s clearance status, please include the following steps and considerations: 1. Discuss/review the student s health history from page 1, paying particular attention to medications that the student may need, any allergies the student may have, and all currently active health problems. Students may be cleared for participation with these conditions provided they are in compliance with, and stable on their medication. 2. Review the Centers for Disease Control vaccine recommendations for his/her travel destination(s) and determine what, if any immunizations the student may need and assist the student in getting these completed (administer, prescribe, refer, etc.). While the medical provider may recommend travel immunizations, it is the student s responsibility to obtain the necessary immunizations for study abroad. 3. Perform a thorough physical examination. Please document on page Please impress on the student that he/she needs to take a sufficient amount of medication to last for the duration of the program abroad, or verify that the medication is locally available and legal. 5. Assess the need for any continued health care, counseling or laboratory testing while abroad so the student can determine the availability of adequate facilities at the program site. 6. Determine the student s level of health and fitness of undertaking participation on a study abroad program and initial health clearance status where indicated on page 4. Students may be cleared for participation as long as, in the opinion of the examining provider, any condition the student may have is under control and has been stable for a reasonable period.

2 For Office Use Only: Date: Received by: Program: Term: Scanned: Uploaded: STUDY ABROAD HEALTH FORM MEDICAL SELF-DISCLOSURE: COMPLETED BY STUDENT Last Name: First Name and Middle Initial DOB (MM-DD-YY): Zag ID#: Gender: F M Other: Permanent Address: Street City, State, and Zip Phone ( ) Person(s) to be notified in case of emergency: Name: Relationship: Address : Phone Hm ( ) Wk ( ) Cell ( ) Medications (including non-prescription) presently taking: Do you have allergies (drug, food, environmental, or other)? YES NO If yes, please explain: Do you have any dietary restrictions? YES NO If yes, please explain: MEDICAL OR HEALTH CONCERNS Please CHECK/MARK conditions/diseases you have or had. If NONE apply, check this box YES? Condition YES Condition YES Condition ADD/ADHD/ Learning Disability Epilepsy/Seizures Mobility Limitations Alcohol or Substance Abuse Eye Problems Mononucleosis Anemia or Other Blood Condition Gastrointestinal Disorder Neurologic Condition Arthritis Head Injury/Concussion/Loss of Consciousness Rheumatic Fever Asthma/Lung Disease/ Pneumonia Hearing Loss Spinal Problems/Injury Bladder/Kidney Disease Heart Disease Stroke Cancer Hepatitis Thyroid Problem Depression/Anxiety/Psychological Disorders Hernia Tuberculosis Diabetes High Blood Pressure Ulcers (Stomach/Duodenal) Ear/Nose/Throat Problems Immunocompromising Condition/HIV Vertigo/Dizziness/Fainting Eating Disorder Menstrual/Gynecologic Problems Vision Impairment Eczema/Psoriasis/Skin Disorder Migraine/Frequent/Severe Headaches Other: Surgery (specify): Fracture (specify): Chronic or long term on-going condition: List date(s) and reason(s) for any hospitalizations: Have you had severe symptoms and/or treatment for emotional or psychological problems? Describe and list current medication. Can you participate in the essential functions of your study abroad program without accommodation? Yes No If No, what type of accommodation if required? Page 1 of 5

3 TRAVEL DATES: COMPLETED BY STUDENT Date of flight leaving the U.S. Date returning to the U.S. / / / / Travel Destination(s): Routine Immunizations Vaccine Doses MM-DD-YY MM-DD-YY MM-DD-YY MM-DD-YY MM-DD-YY POLIO (IPV: 4 doses recommended by age 6) Or (OPV: 5 doses recommended by age 6) DIPHTHERIA-PERTUSSIS Tetanus (DTaP/Baby Shots) 5 Doses by age 6 TETANUS - DIPHTHERIA (DT) or (Td) Booster every 10 years 3. MEASLES (Rubeola) 2 doses RUBELLA (German Measles) 1 dose on or after 1 st birthday IMMUNIZATION RECORD and EVALUATION: COMPLETED BY MEDICAL PROVIDER MUMPS 1 dose on or after 1 st birthday MMR (Measles, Mumps, Rubella) If given instead of individual immunizations HEPATITIS A (Optional) HEPATITIS B (Optional) MENINGOCOCCAL (Meningitis) or Measles Serology: Date: Titer: 1. or Rubella Serology: Date Titer: 1. or Mumps Diagnosed by Physician Date: VARICELLA (Chickenpox) Or Chickenpox diagnosed by Physician Date: PPD - TUBERCULOSIS SKIN TEST Date Read mm Induration Recommended Travel Vaccines After reviewing vaccinations recommended or required by the Centers for Disease Control for the study abroad destination(s), please indicate any travel vaccinations given below. This may include, but is not limited to, Japanese encephalitis, Malaria prophylaxis, Rabies, Typhoid fever, Yellow fever, etc. Vaccine MM-DD-YY Comments Page 2 of 5

4 PHYSICAL EXAM: COMPLETED BY MEDICAL PROVIDER Height: Weight: Blood Pressure: Pulse: EVALUATION OF SYSTEMS System Normal findings? Description of Abnormalities HEENT Yes No Respiratory Yes No Cardiovascular Yes No Gastrointestinal Yes No Endocrine Yes No Musculoskeletal Yes No Integumentary Yes No Renal/Urinary Yes No Lymphatic Yes No Nervous System Yes No Does this student have any history of allergy, anaphylaxis, or asthma? If yes, please explain: Is the student currently undergoing treatment for any medical condition? If yes, please explain: Does the student have any physical limitations that we should be aware of? If yes, please explain: Yes Yes Yes No No No Are you aware of any history of psychological disorders (i.e. depression, anxiety, eating disorders, etc.)? If yes, please explain: Yes No Please include any additional information that you deem necessary in your assessment of the student s physical health. Page 3 of 5

5 MEDICAL CARE PROVIDER CLEARANCE: COMPLETED BY MEDICAL PROVIDER I have thoroughly reviewed the student s health, referring to the student s health history provided on this forms, and medical records on file. Based on this information, as well as my current observation of this student, to the best of my knowledge: (Initial one box below) Student is CLEARED. I have reviewed the patient s medical history. There are no medical or mental health contraindications to participation in this study abroad program. I have discussed with the student all vaccinations recommended by the Centers for Disease Control for his/her travel destination(s). Student is NOT CLEARED. There are medical or mental health contraindications to participation in the study abroad program that the student has chosen. Student is CLEARED with additional considerations. I have reviewed the student s medical history. I have discussed with the student all vaccinations recommended by the Centers for Disease Control for his/her travel destination(s). Additional considerations explained below. Student requires an accommodation or support to assist in his/her medical/psychological conditions in order to participate in the study abroad program. Indicate and describe the treatment plan in place and comment on the student s stability. Printed Name: Signature: Medical Degree: DATE: / / Office Contact Information: Address: Phone Number: Fax Number: Page 4 of 5

6 STUDENT ACKNOWLEDGEMENTS: COMPLETED BY STUDENT Please read each section carefully and sign below. I. ACCURACY OF INFORMATION CONTAINED HEREIN I hereby verify that all the information contained in this form is accurate and acknowledge that failure to provide accurate information may result in my dismissal from the program. II. III. IV. EMERGENCY CARE WHILE ABROAD I hereby consent to medical personnel designated or authorized by the Gonzaga University or administrator(s), in case of a medical emergency involving myself while attending the program to perform upon or administer any necessary medical or surgical treatment. In addition, I must personally consent to said medical procedure if I am physically and emotionally capable of consenting at the time such treatment is required. In the event Gonzaga University is required to rely on this consent to authorize necessary medical care and treatment, I, individually and jointly, agree to pay for treatment or reimburse Gonzaga University if it has paid for the treatment. I further agree to pay any costs and attorney fees if Gonzaga University has to sue me for repayment. ACKNOWLEDGEMENT OF INTERNATIONAL AVAILABILITY FOR MEDICATIONS I am aware that particular prescription medications which I take may be or are unavailable in the country for this study abroad term. I understand that my choices include: talk to my doctor, look for an alternative medication that is available, cancel my plans before embarkation due to medical necessity with a full refund, look for a different study abroad country or program, or bring my choice of medication with me. If I choose to take medication with me, I understand that bringing on my trip any prescription medications that do not comply with local law could result in action against me by local authorities. I accept the consequences of this decision and understand that medical care is my responsibility and I will be subject to the laws of localities and countries in which I am traveling. I hereby release Gonzaga University from any responsibility for my medication decisions and acknowledge that I have acted independently in this decision. FUTURE MEDICAL PROBLEMS Should you develop significant health problems between the time you have completed this form and commencement of the program, which may influence your participation in the program, I understand it is my responsibility to notify the Study Abroad Office at Gonzaga University. A medical report should accompany this notification. V. TRAVEL VACCINATIONS While my medical provider may recommend travel immunizations, I understand it is my responsibility to obtain the necessary immunizations for travel abroad. I have reviewed the vaccinations recommended by the Centers for Disease Control for my travel destination(s) located at the following link: I acknowledge that traveling abroad without receiving all of the recommended vaccines poses a potential risk to my health. SIGNATURE: DATE: / / PROGRAM: TERM: Page 5 of 5